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Older existing facilities can be complex in the way they have expanded over the years — piping systems exceeding their limits, adding valves for bypass abilities, replacing and updating equipment. The list goes on.
Let us evaluate these older facilities and determine what the best approach is for handling an event such as the COVID-19 pandemic:
• What is the emergency preparedness program to reduce the strain put on the facility’s oxygen and medical air systems?
• What is the storage capacity of the bulk oxygen storage?
• What is the capacity of the vaporizers?
• Is there an automatic switchover on the vaporizers? If so, what is the time frame between switchovers?
• What is the delivery pressure for oxygen to the building (55 pounds/square inch (psi) to 58 psi)?
• What is the capacity of the medical air system?
• Where is the emergency oxygen supply connection?
• Does the facility have an indoor emergency supply for oxygen (cylinders with a manifold)?
• Which part of the piped oxygen or medical air system is the Emergency Department (ED) located?
• Which part of the piped oxygen or medical air system is the Intensive Care Unit located (ICU/CCU)?
• Which part of the piped oxygen or medical air system is the Med Surge patient floors located?
The ED, ICU/CCU and Med Surge areas will see the biggest impact due to increased patient use of oxygen and medical air.
Due to physicians figuring out how to best handle COVID-19 and vaccines being introduced, the usage of oxygen and medical air has come down considerably to treat the less-severe cases.
However, we still have severe cases of COVID-19 requiring a high use of oxygen and medical air. We may not see the same number of severe cases as we did over the past year, but we could still see most of the beds in a facility being taken up by COVID-19 patients in the future.
Facilities will be updating their emergency preparedness documents to incorporate what they have learned over this past year and the best protocols to handle a similar pandemic in the future. The documents will explain what their facility will need to follow to be best prepared for an influx of patients.
Understanding Medical Gas Needs
Before a facility sees an influx of patients, management needs to fully understand its medical gas systems and capabilities. This requires a competent engineering firm to evaluate the source equipment and the line sizes of the piping system throughout the entire facility.
The best way to do this is to have an up-to-date, accurate set of as-builts. They will help the engineer evaluate pipe sizes to specific areas of the building and how far the piped system can be pushed.
Next, the emergency preparedness team and the engineer need to sit down and discuss where the facility intends to place severely ill patients. The engineer may identify issues or concerns before placing patients in those areas.
Now that the engineer knows the locations of areas expecting to see an influx of patients, the next step is to understand the treatment of patients in these areas. Will they be using ventilators? Will they have extracorporeal membrane oxygenation (ECMO) machines and nitric oxide? Will they use Airvo air flow units instead? Is new equipment or procedures to be used? What are those flow rates? Which gas is to be used?
These are all very important questions the engineer needs to fully understand to prepare a facility for increased patient usage. In the past, engineers typically would never know how a patient is being treated. Still, it is an important part of understanding how to best tweak the facility’s piping systems to avoid issues.
Next, the engineer needs to determine how to achieve the highest flow rates from the piped gas. In most cases, simply increasing the pressure at the source equipment will suffice. However, that may not be the case in some older facilities.
In many cases, the engineer can recommend the bulk oxygen site pressure regulators be increased to deliver 60 psi to 65 psi or 65 psi to 70 psi, depending on the size of the facility. As part of the system’s pressure is increased, it also is recommended that the facility’s maintenance department monitor the daily bed count and severe cases within the facility.
The maintenance staff should also record pressures and census daily; they will need to raise or lower pressures accordingly. In many cases, it is recommended that the bulk site vendor do this.
Setting Emergency Preparedness Standards
Once bulk site delivery pressure has been determined, the engineer can provide a set standard of rules in which to follow. The engineer will determine how many ventilators, ECMO vents, Airvos — and anything else physicians may want to treat a patient with — can be placed on a section of pipe within a patient area.
It is recommended to provide a floor plan for the area with guidelines for nursing staff to follow. This document can live within the emergency preparedness document, which should be easily accessible and distributed to the areas that will be impacted.
The floor plan should indicate the following:
• Medical gas pipes and line sizes.
• Electrical outlet capabilities.
• Mechanical ventilation requirements.
• The number of Airvos at specific flow rates for each room based on pipe size.
• The number of ventilators at specific flow rates for each room based on pipe size.
• The number of ECMO ventilators at specific flow rates for each room based on pipe size.
• Quantities shall be based on the elevated pressure being delivered to the area.
The engineer will determine capacities for areas based on the elevated pressures and friction losses. There should be two or three emergency preparedness floor plans based on the delivery pressures. This will aid the nursing staff in understanding that their treatment capabilities are based on what the facility's maintenance staff indicates the delivery pressure is set for that day. It requires daily communication between the maintenance staff and the nursing staff.
With the increased demand on the bulk oxygen system, the facility may see an increase in the icing of its vaporizers. A best practice for maintenance staff is to use a shop fan blowing across the vaporizers.
In the future, a facility may want to expand its bulk oxygen pad to add another bulk tank and vaporizers and handle a heavier load.
A facility may wish to increase its pressure from the bulk tank site into the building permanently. It will need to provide pressure-reducing valves inside the building to increase pressure for certain areas to handle heightened demand. This allows existing pipe sizes to manage more flow but at a higher friction loss.
Auxiliary connections for medical air and medical vacuum source equipment are a good and inexpensive safety measure. They would be located near the exterior of the building (the loading dock area); they also can be found at the exterior wall with an access panel labeled “auxiliary medical gas connections.”
If a facility were to experience a source equipment failure or other issues, a portable system could be brought in to take over until the main system is repaired or replaced and put back into service.
Another area to be evaluated is the waste system. How will it handle bio-containment waste? That will be another topic to discuss next time
Being prepared is half the battle for all facilities, as they never know what they will face in times of crisis. A motto I like to live by is, “Prepare for the worst, hope for the best.”
A facility needs to be prepared by incorporating all or some of the following medical gas concepts:
• Auxiliary connections.
• Additional pressure-regulating valves for the oxygen system inside the building.
• Current and accurate set of as-builts for all mechanical, electrical and plumbing systems.
• A documented plan to increase oxygen, medical air and medical vacuum supply to meet the demand. This includes friction loss charts for increased flow rates for existing piping.
• Plans in place with the bulk oxygen vendor to place temporary bulk tanks and vaporizers on an extended pad.